Primary care management for patients receiving long-term antithrombotic treatment: A cluster-randomized controlled trial.

Purpose: To examine whether applying case management in general practices reduces thromboembolic events requiring hospitalization and major bleeding events (combined primary outcome). Secondary endpoints were mortality, frequency and duration of hospitalization, severe treatment interactions, adverse events, quality of anticoagulation, health-related quality of life and intervention costs, patients' assessment of chronic illness care, self-reported adherence to medication, GP and HCA knowledge, patient knowledge and satisfaction with shared decision-making.
Methods: Cluster-randomized controlled trial undertaken at 52 general practices in Germany with adult patients with a long-term indication for oral anticoagulation. The complex intervention included training for healthcare assistants, information and quality circles for general practitioners and 24 months of case management for patients. Assessment was after 12 and 24 months. The intention-to-treat population included all randomized practices and patients, while the per-protocol analysis included only those that received treatment without major protocol violations.
Results: The mean (SD) age of the 736 patients was 73.5 (9.4) years and 597 (81.1%) had atrial fibrillation. After 24 months, the primary endpoint had occurred in 40 (11.0%) intervention and 48 (12.9%) control patients (hazard ratio 0.83, 95% CI 0.55 to 1.25; P = .37). Patients' perceived quality of care, their knowledge, and HCAs' knowledge, had improved significantly at 24 months. The other secondary endpoints did not differ between groups. In the intervention group, hospital admissions were significantly reduced in patients that received treatment without major protocol deviations.
Conclusions: Even though the main outcomes did not differ significantly, the intervention appears to have positively influenced several process parameters under 'real-world conditions'.
Competing Interests: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Juliana J. Petersen has been a co-investigator in the PANORA study (‘Prevalence of anti-cyclic citrullinated peptide (CCP) positivity in patients with new non-specific onset of musculoskeletal symptoms, possibly related to early rheumatoid arthritis in general practices in Germany’), which is being conducted by the Fraunhofer Institute and financed by Bristol‐Meyer Squibb. She is employed by the Institute of General Practice of Goethe-University Frankfurt and has never personally received financial remuneration from a pharmaceutical company. Karola Mergenthal is employed as project manager in the PANORA study. She has also never personally received financial remuneration from a pharmaceutical company. Andrea Siebenhofer received funding from the Federation of Austrian Social Insurance Institutions (HVB) for the preparation of a systematic review on self-management of oral anticoagulation in 2014 and was financed by ROCHE Diagnostics to carry out a study on self-management of oral anticoagulation from 2002-2005. Sebastian Harder has received honoraria for scientific lectures from Boehringer Ingelheim GmbH, Pfizer GmbH, Daiichi Sankyo GmbH, and Bayer AG. The other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.